1
Q
1st heart sound:
A
Caused by tricuspid & bicuspid valves (AV valve closure)
2
Q
2nd heart sound
A
Caused by closure of pulmonary and aortic valves (semilunar valves)
3
Q
3rd heart sound
A
- Heard only among children and young adults
- Best heard when ask patient to lie on left side
- Disappears in 30’s
- If present in older adults may signify heart failure @ Erb’s point or mitrovalve area
- Caused by ventricular filling
- Vibration of ventricles
- Blood rushing from atria to ventricles
4
Q
4th heart sound:
A
- Heard after 1st heart sound
- Heard in people w/ heart disease or MI
5
Q
Projection Areas of Valve Sound:
- Pulmonic:
- Aortic:
- Tricuspid:
- Mitral:
- Erb’s point:
A
- 2nd left intercostal space lateral to sternum
- 2nd right intercostal space lateral to sternum
- over lower portion of sternum
- 5th left intercostal ½ inch medial to the midclavicular line
- S2 sound- in 3rd left intercostal space
6
Q
Mapping out the Heart:
-Superior border:
- Right border:
- Inferior border:
- Left border:
A
– a line connecting the inferior margin of the 2nd left costal cartilage and superior margin of 3rd right costal cartilage
- line connecting 3rd right costal cartilage to 6th right costal cartilage
- line connecting 6th right costal cartilage to apex beat are (3.5inches from midline at left 5th intercostal space)
- connects left ends of superior and inferior border
7
Q
Nerve Supply of the Heart
Cardiac Plexus of Nerves Contain:
A
- Preganglionic parasympathetic fibers (vagus nerve)
- Vagal afferent fibers-concerned with cardiac reflexes
- Postganglionic sympathetic fibers (T1-T4/5)
- Sympathetic afferent fibers-detects ischemic pain
- NOT sensitive to touch, cutting, cold, or heat
8
Q
Cardiac Conduction System:
SA node:
A
SA node:
- Superior end of sulcus terminalis
- In subepicardium (under epicardium)
- Near opening of SVC
- Natural pacemaker of the heart
- 70-80bpm
9
Q
AV node:
A
- If SA node is damaged or destroyed AV node takes over as the pacemaker
- Provides impulses 40-60bpm
10
Q
Purkinje fibers
A
-Ends in sub-endocardium
11
Q
FUN FACTS CLINICALLY
A
- IF SA node & AV node are both damaged- will have multiple pacemakers= ventricular fibrillation- heart quivers =doesn’t pump efficiently-must force multiple pacemakers to synchronize.
- Transplant=DENERVATED- no more nerve supply from the vagus nerve or sympathetic nervous system-when exercise doesn’t pump any harder= DELAYED RESPONSE; when resting, then starts to increase through adrenal glands= LONG DURATION
12
Q
“SKELETON OF THE HEART”
A
Composed of fibrous or fibrocartilaginous tissue
-Forms the central support of the heart
- Fibrous rings that give circular form and rigidity to
- the AV orifices and roots of pulmonary trunk and aorta
- Provide attachment to valves and prevent the outlets from becoming dilated
- Also provides attachment to cardiac muscle fibers
13
Q
Venus Drainage:
Coronary Sinus:
- Anterior Cardiac Veins: drain directly to RA
- Vena Cordis minimi: drains directly into atria
A
- Great cardiac vein-accompanied by anterior interventricular artery
- Middle cardiac vein- accompanied by posterior interventricular artery
- Small cardiac vein-accompanied by right marginal artery
- Left marginal vein-accompanied by left marginal artery
- Left posterior interventricular vein-accompanied by left posterior ventricular artery
14
Q
Right Coronary Artery:
A
RA & RV
15
Q
Circumflex-
A
LA and LV
16
Q
Pericardium:
A
- Located in the middle mediastinum
- Posterior to the body of the sternum
- 2nd-6th costal cartilages
- Anterior to T5-T8 vertebrae
- Double-walled fibrous sac which encloses the heart and root of the great vessels: conical in shape
- It is bound by pericardiacophrenic and sternopericardial ligaments
- Cavity contains 5-30ml of serous fluid
- Arterial supply: branches from the internal thoracic, pericardiacophrenic, musculophrenic, and inferior Phrenic arteries, and the thoracic aorta
- Nerve supply: phrenic and vagus nerves, sympathetic trunks
17
Q
Fibrous and serous pericardium
A
Fibrous pericardium: outer tough fibrous layer made up of dense irregular CT
o Serous pericardium: parietal layer and visceral layer (epicardium)
18
Q
Pericarditis:
A
inflammation of the pericardium; causes increased secretion of serous fluid-surface becomes rough
19
Q
Pericardial effusion:
A
increased secretion of fluid-due to infection
20
Q
Cardiac tamponade
A
blood coming out to sac but still in pericardium-starts to compress the heart and therefore compression of great vessels especially SVC
21
Q
Pericardiocentesis:
A
put needle into pericardium then extract
22
Q
External Features of the heart:
A
- Pyramidal shape; fibrous framework
- External sufaces: sternocostal, diaphragmatic, & pulmonary; a base; apex
- Coronary sulcus: groove that separates atria from ventricles (aka AV sulcus)
- Interventricular sulcus: b/w ventricles
- Sulcus terminalis: along inferior/superior vena cava (right side) – inside is crista terminalis
23
Q
Coronary arteries and branches
A
- RCA: marginal and posterior interventricular arteries
- LCA: anterior interventricular and circumflex arteries
24
Q
Coronary sinus and cardiac veins
A
- Posterior cardiac veins drain directly into coronary sinus
- Anterior cardiac veins drain directly into RA
- Coronary sinus drains into RA
25
Surfaces of the Heart:
- Anterior or sternocostal surface
- Left pulmonary surface:
- Right pulmonary surface:
- Inferior or diaphragmatic surface:
- Base:
- Apex:
- : is formed mainly by the RV
- faces left lung and consists of the LV and part of the LA
- faces the right lung and consists of the RA
- is formed by the LV and partly by the RV; it is closely related to the central tend on of the diaphram
- is the posterior aspect of the heart formed mainly by the LA facing the bodies of T6-T9 vertebra
- is located in the left 5th ICS at the MCL and is formed by the inferolateral part of the LV
26
Borders of the Heart:
- Superior: formed by
- Inferior: formed by the
- Left: formed mainly by
- Right border: formed by
- LA and RA and auricles
- RV and slightly by the LV
- LV and partly by left auricle
- RA and extends from SVC to IVC
27
Internal Features of the Heart:
| RA:
```
crista terminalis
sinus venarum
pectinate muscles
venous openings
fossa ovalis
tricuspid orfice
```
28
LA:
Pulmonary vein openings
| Mitral orifice
29
RV:
- Conus arteriosus (infundibulum)
- Paillary
- Traveculae carnae
- Moderator band
- Chordae tendineae
- tricuspid valve
30
trachea
- fibroelastic wall with U shaped bars of hyaline cartilage
- begins at C6 below cricoid cartilage
- ends at sternal angle between T4 and T5
- on deep inspiration T6
31
4 parts of parital Pleura
- Costal
- Mediastinal
- Diaphragmatic
- cervical
32
2 pleural recesses
Costodiaphragmatic (down by diaphragm)
costomediastinal
33
contents of the hilum of the lung
a pulmonary artery
two pulmonary veins
a main bronchus
bronchial vessels
34
right lung has 3 lobes
superior, middle and inferior
superior and middle seperated by horizontal fissure
middle lobe and inferior lobe seperated by oblique fissure.
35
left lung has two lobes
the superior and the inferior
seperated by the oblique fissure
the lingula is a remnant of the middle lobe
36
grooves found in the left lung
arch of the aorta, cardiac impression, descending aorta, groove for subclavian
37
grooves for right lung
groove for superior vena cava, groove for azygos vein, groove for esophagus
38
primary bronchi (how do you tell them apart)
right side is wider, shorter and more vertical
left is longer, thinner and more transverse
the two bifricate from the carina
39
ligamentum arteriosum
ligament that connects the arch of the aorta to the pulmonary artery
40
sympathetc (for lungs)
thoracic splanchnic
bronchodialation
decreased bronchial gland secretion
vasoconstriction
41
parasympathetic (lungs)
Vagus
bronchoconstriction
increased bronchial gland secretion
mild to no vasodialation
42
the Diaphragm
boundary between thoracic and abdominal cavities
higher on the right than on the left due to the right lobe of the liver
origin: sternal portion: back of xiphoid process
costal portion- inner surface of lower 6 rib cartilage
vertebral portion- arcuate ligaments and upper lumbar vertebrae
Insertion- central tendon
43
openings in diaphragm
caval
esophageal
aortic
- T8- IVC right phrenic nerve
- T10- esophagus, vagal trunks, left gastric vessels
- T12- aorta, thoracic duct, azygos/hemiazygos
44
nerve supply to diaphragm
phrenic, GSE, motor supply for whole diaphragm and sensory supply for central
sensory to the peripheral part of diaphragm is by lower intercostal nerves and the convey GSA, GSE, GVA
45
Which of the following arteries run along the lesser curvature of the stomach?
right gastric
46
Which of the following structural landmarks is used to delineate the fundus from the body of the stomach?
cardiac notch
47
Which vessel runs along the superior border of the pancreas?
splenic artery
48
The main pancreatic duct joins the common bile duct as it enters the second part of the duodenum, forming a common tiny space called the:
hepatopancreatic ampula
49
n which abdominal region is the spleen located?
left hypochondriac
50
Which of the following statements is TRUE regarding the spleen?
its located DEEP to ribs 9-11
51
Which of the following statements is TRUE regarding the small intestine?
Aggregates of lymphoid nodules called Peyer's patches are located in the ileum
52
Which of the following statements are TRUE regarding the small intestine
The mesenteric attachment of the ileum is located to the right of the aorta.
53
The sigmoid colon extends from the ____________ to the ____________.
pelvic inlet to s3 level
54
The three bands of longitudinal muscles found in most of the large intestine are called:
tenia coli
55
The parietal peritoneum receives sensory innervation via
GSA fibers to spinal levels T7-L1
56
Which type of peritoneal extension connects the stomach to another viscus or to the abdominal wall?
Omentum
57
Which of the following structures is considered an intraperitoneal organ?structure?
jejunum
58
The greater omentum attaches from the greater curvature of the stomach to the which of the following structures?
transverse colon
59
Which of the following structures is NOT contained within the the hepatoduodenal ligament?
hepatic vein
60
Which of the following is the embryonic remnant of the umbilical vein?
ligamentum teres
61
Which of the following structures is located between the right lobe and the caudate lobe of the liver?
Inferior Vena Cava
62
A patient has liver cirrhosis with portal vein hypertension. PE findings show caput medusae. Which portocaval anastomosis is affected in this condition?
paraumbilical veins with superficial epigastric veins
63
Which of the following types of nerve fibers is NOT a component of the celiac plexus?
postganglionic parasympathetic fibers
64
Which of the following is a function of the gallbladder?
concentrates bile
65
Congenital heart disease is the most common cardiac condition in childhood and most frequently results from:
multifactorial inheritance
66
The most common congenital defect of the heart and great vessels associated with congenital rubella syndrome is:
patent ductus arteriosus
67
A female infant has congestive heart failure and was diagnosed to have patent ductus arteriosus. Which of the following statements is correct?
In the fetus, most of the blood from the pulmonary trunk flows into the aorta.
68
Sufficient amount of surfactant is produced during which period of lung development?
Terminal Saccular Period (26 weeks to birth)
69
Which transverse body plane passes through the body midway between the jugular notch and the symphysis pubis?
transpyloric plane
70
McBurney's point is located:
along a line drawn between the umbilicus and the right ASIS
71
Which ligament attaches to the ASIS and pubic tubercle?
inguinal ligament
72
Which of the following marks the inferior edge of the posterior rectus sheath?
arcuate line
73
Which structure forms the floor of the inguinal canal?
inguinal ligament
74
Which of the following forms the medial boundary of the inguinal triangle?
semilunar line
75
Which of the following external features of the heart is located between the two atria and two ventricles?
coronary sulcus
76
The apex of the heart lies beneath which surface landmark
fifth left ICS at MCL
77
Which of the following is located only in the right ventricle?
conus arteriosus
78
During a heart transplant, which of the following nerve fibers can not possibly be cut by a scalpel?
preganglionic sympathetic fibers
79
When viewing the cardiac silhouette in a chest x-ray, the inferior border of the cardiac silhouette is formed mostly by which structure?
right ventricle
80
During deep inspiration, the trachea can extend all the way down to which vertebral level
T6
81
At the posterior chest wall, the right oblique fissure of the lung is located at the level of which bony landmark?
SP of T4
82
The horizontal fissure of the right lung ends anteriorly at which surface landmark?
fourth ICS
83
Which structure forms an impression on the mediastinal suface of the left lung?
arch of aorta
84
The tertiary bronchi are also know as the ___________.
segmental bronchi
85
9 quadrants of body
right/ left hypochondrium, epigastric (in middle top)
right/left flank, umbilical in center
right/left groin pubic region in center
86
murpheys point
location of the gall bladder
intersection of costal margin and right mid clavicular line
87
McBurney's point
location of appendix
line from ASIS to belly button medial 2/3, lateral 1/3
88
rectus sheath:
above umbilicus
below umbilicus
- above theres a posterior and anterior rectus sheath
- below theres only anterior rectus sheath
* arcurate line marks inf. edge of rectus sheath
89
Valsalva's maneuver
holding breathe to increase inter abdominal pressure to aid in taking a shit
90
Umbilical folds:
Lateral
Medial
Median
- lateral formed by inferior epigastric vein & a.a.
- Medial formed by remnants of umbilical arteries
- median formed by remnant of urachus
91
the inguinal canal (boundaries)
floor- inguinal ligament
roof- internal oblique and transverse abdominis
anterior- aponeurosis of external oblique
posterior wall- transversalis fascia
92
what passes through the inguinal canal
spermatic chord and ilioinguinal ligament
females= round ligament of uterus and ilioinguinal nerve
93
development of the inguinal canal
peritoneum- process vaginalis, tunica vaginalis
transversalis fascia- internal spermatic fascia
internal oblique M.-cremasteric fascia
external oblique aponeurosis- external spermatic fascia
94
failure of process vaginalis to close results in
an indirect inguinal hernia
95
3 layers that cover the spermatic cord
external spermatic fascia, cremasteric fascia and internal spermatic fascia
96
cryptorchidism
failure of testes to descend, results in infertility and testicular cancer
97
contents of spermatic cord
vas deferens,
testicular, deferential, and cremasteric a.a.
pampiniform plexus of veins
genital branch of the genitofemoral nerve GSE/GSA
autonomic and sensory nerves
lymph vessels
remnants of process vaginalis
98
dartos muscle
wrinkling of balls due to cold or sexual excitation
99
cremasteric muscles
draws balls up towards body
the reflex test is done by stroking inner thigh and seeing if balls do rise
100
borders of inguinal triangle
| aka hesselbach's triangle
```
lateral= inferior epigastric vessels
medial= rectus abdominis
inferior= inguinal ligament
```
101
Parietal peritoneum
visceral peritoneum
lines the walls of the cavities (GSA from T7-11)
covers the organs (GVA)
102
mesentary
double layer of peritoneum that connects an INTROPERITONEAL ORGAN TO THE BODY
103
peritoneal ligament
organ to organ
104
omentum
stomach to another viscus or to abdominal wall
105
introperitoneal
rectoperitoneal
- organ is covered by peritoneum
(stomach,liver, spleen, gallbaldder)
- organ which is partially or not covered by peritoneum
(kidneys, IVC,pancreas(besides tail),)
106
greater omentum
lesser omentum
greater curvature of stomach to transverse colon
lesser curvature of stomach to liver
107
portal triad
Common Heptaic a.a.
Hepatic portal vein
common bile duct
108
foramen of winslow
| aka epiploic foramen
superior- caudate lobe of liver
anterior- hepatoduodenal ligament
inferior- 1st part of duodenum
posterior- IVC
109
portal vein
splenic and superior mesenteric make up the portal vein
110
caput medussa
dialation of superficial epigastric veins
111
Nerve deal for liver
Preganglionic parasympathetic= Vagus
Postganglionic sympathetic=celliac ganglion
GVA fibers
112
common bile duct is composed of
cystic duct and common hepatic duct
113
hepatomegaly
enlargment of the liver
114
jaundice
yellowish discoloration of skin due to hyperbilirubinemia
115
alcoholic cirrhosis
destruction of hepatocytes and replacment by fibirous tissue, usualy leads to portal hypertension
116
cholelithiasis or gallstones
crystalization of biles salts and cholesterol
General Anatomy
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